You’ve reviewed the letter from your insurance company that says they’re not going to pay for a service you or a loved one has already had. When the rage has cooled and you re-read the letter, it states the reasons they denied payment, which may or may not make sense to you. Terms like “Didn’t meet medical necessity” or “More information is required” or “Pre-authorization wasn’t submitted.” It may reference pages in a document you’ve never seen or heard of but sounds important.
You’ve decided this isn’t OK and you’re going to appeal. If you want the best chance at success, how should you proceed?
Action Number 1: Go to your insurance online portal to find the contract for your insurance (aka Certificate of Coverage or Summary Plan Description). Download it. Be prepared. It’s a big document. And now you’re probably scratching your head trying to figure out what’s next.
Insurance companies receive thousands of appeals for denials of coverage. First the appeal is reviewed to determine if it’s been submitted correctly (an administrative review). If not, it will be returned for the offending “administrivia” to be addressed. When the appeal has been submitted correctly, it is routed to a reviewer. That person reads (sometimes it’s more like “scans”) the appeal to determine if there is appropriate new information that can be considered. If there is, and the information addresses the reason for the denial, the denial may be overturned and the claim routed for payment. If the appeal you submitted doesn’t provide appropriate, or enough information, the denial is upheld, and they still won’t pay the charges.
Improve your chances
Admittedly it can feel like a bit like a guessing game to provide the “right” information an insurance company needs to pay a denied claim. You can increase your odds of an appeal being successful if you follow a couple of key strategies.
- Pay careful attention to the instructions in the denial letter about the steps to take. This can help you avoid the most common administrative rejections.
- The most successful appeals must relate to the specific reason the insurer states they denied coverage. This always ties back to the policy language in that big document you downloaded.
- When payment is denied because the charges “didn’t meet medical necessity” it doesn’t mean the care wasn’t necessary. This is a computer generated response that means some information may not have been provided, or a treatment isn’t FDA approved, or approved for your policy. Because you or your doctor believes your insurance should cover something means you have to talk to a claims representative to understand why the insurer’s computer defaulted to this language. And if something has been denied because it wasn’t “medically necessary” your doctor is going to be an important ally and his or her letter, or doctor to insurance company doctor review may be critical to “proving” why something was necessary for you.
- A successful appeal depends on a challenge specific to the policy language. Insurance is a contract, and the contract language is what’s enforceable. Personal circumstances can influence a decision, but only if the challenge to the policy language is sound.
Outcomes
The appeal process requires research and a thoughtful and concise letter with substantiating evidence. An appeal isn’t a guarantee of success, but there is some evidence that persevering through the entire appeal process (most policies spell out several levels of appeal) increases the odds of success. Still every situation is different, so let’s take a look at the cases from our last post and see if appealing was helpful.
- Carla’s* mother had been hospitalized for a week for a hip replacement, and discharged to a skilled nursing facility for rehab. Three weeks after her admission, her mother received a notice that her Medicare plan was denying payment for her care because she wasn’t participating in therapy. Should they appeal?
In our practice, if Carla determined that she could get medical records from the skilled nursing facility quickly (within 2-3 days) to review what the physical therapy notes said as well as obtain the policy language, we would consider an appeal in a case like this. This situation really speaks to family members communicating often with nursing and therapy to determine how a loved one is progressing before a notice of termination of coverage is issued. It shouldn’t be a surprise, but often receiving the notice is the first time a family member hears this. Nonetheless, depending on Carla’s mother’s Medicare coverage, and what the therapy notes say, this situation can sometimes be overturned and coverage reinstated by appealing.
- Dave* had foot surgery that required the implantation of a new type of manufactured material. The surgery had been pre-approved, but his insurance company denied coverage for the manufactured material, resulting in a $12,000 bill from the hospital.
This situation is actually similar to a case from our practice that was featured in a Time magazine article, titled “The Hidden Cost of ‘Surprise’ Medical Bills.” After reviewing the policy language, and the insurer’s policy for implanted materials, the denial was policy-based and the appeal was unsuccessful. We worked with the manufacturer of the material to provide evidence that the policy was restrictive, but the insurer held firm. However executing the appeal process and working closely with the surgeon, who was influential at the hospital, did result in the excess charges being removed from the patient’s bill.
- Elena’s* ovarian cancer had advanced, and her oncologist felt that the next medication she should try, which in his experience had shown some good results, was only FDA approved for breast cancer. Her insurance company denied coverage for the use of this very costly medication as not “medically necessary.” It certainly didn’t mean she didn’t need the medication, only that it didn’t meet the policy’s terms of what they were legally required to pay for under her policy.
Elena’s situation was time sensitive. Her physician had already initiated an expedited appeal, providing published studies that showed this drug was used for ovarian cancer in other countries. The insurer upheld the denial because the policy stated clearly that medications were only covered for FDA approved indications. One option is to look for a clinical trial using this medication; the other is to work with the pharmaceutical company to determine if they had a compassionate use protocol for unapproved indications (medications are often dispensed at no charge under these programs), or if they had a patient assistance program for patients whose insurance plan didn’t cover the drug. As it turned out, there was such a program and Elena was started on the medication within 2 days.
Should you appeal? It depends. It takes time, energy, and perseverance. Keeping the end in mind (what you ultimately want to achieve) is an important part of that evaluation. If your insurance has denied payment for your care, call us. We can help.
*Names and some details changes to protect confidentiality.